Ohio Nurse Practice Act: 2 Hour Category A

2.00 Contact
Hours:

This continuing nursing education activity was approved by the Ohio Nurses Association (OBN-001-91), an accredited approver by the American Nurses Credentialing Centers Commission on Accreditation.
Approval valid through 2/5/2018. ONA #16568 has received ONA approval for 2 Category A contact hours.

Are you a nurse? How do you know? It is only when you pick up the Nurse Practice Act written by the State Legislature of the state in which you are applying for licensure that you can know if you meet the specific definition of who may go by the title, nurse.

Each state governing body has the duty and obligation to its citizens to define who may be called a nurse, what the process is for achieving and maintaining that title, what a nurse may or may not do, who they are responsible to, and how correction of those who fail to comply with the state Nurse Practice Act (NPA) will be applied. Be aware while all NPAs discuss similar topics and share comparable content the Nurse Practice Acts of any two states will not be identical!

As a professional you are legally responsible to remain in compliance with the laws and regulations that govern you. Each licensed medical professional works under laws, statutes, and standards derived from local, state, and federal governing bodies in addition to the professional practice guidelines that apply.

Maybe it is time to dust off your copy of the Practice Act you have sworn, yes, sworn, to abide by. An application for professional licensure with acceptance is a legally binding contract to uphold your practice to the level mandated by that authorizing body. "The practice of nursing is a right granted by a state to protect those who need nursing care. Safe, competent nursing practice is grounded in the law as written in the state nurse practice act and its rules. The laws of the nursing profession can only function properly if nurses know the current laws governing practice in their state. Ignorance of the law is never an excuse." (NCSBN, 2013).

Well, no need to rush to a bookseller. Most states have copies of their Nurse Practice Acts on the internet, or available on request from your state board of nursing.

How about we start at the basics, picking an example NPA and looking at the high points? How about, Ohio:

The goal is safety. The NPA (chapter 4723 of the Ohio Revised Code (ORC), are statutes, with the expressed goal of protecting the public from unsafe care by ensuring that a minimum set of requirements are met and maintained by those whose practice is in that area the state defines as nursing. An Adjunct document is the Ohio Administrative Code (OAC) chapters 4723-1 though chapter 4723-27. The OAC is a set of rules that assist in implementation and interpretation of the ORC.

Before you reach for the migraine relief kit, be assured that much of what we as a society consider being a nurse (singular) and nursing (the field of endeavor) is consistent from state to state. The National Council of State Boards of Nursing (NCSBN) has even developed a 'Model Nursing Practice Act' to help government stay abreast of the profession and assist in the crafting of suitable laws and statutes. Details will vary however, and the amount of difference from one state to another can catch a professional by surprise!

To encourage consistency across state lines, the National Council of State Boards of Nursing developed a Model Nursing Practice Act. This is available at; http://www.ncsbn.org.

One area of considerable variance is in that entity commonly known as the state Board of Nursing. In Ohio the Board of Nursing acts as the administrative agency charged with implementing and interpreting the state's NPA. This authority is granted to the Board by the NPA itself. However, the Board has no actual control over the formation of the Act. That burden is the duty of the state legislature who listens to suggestions from the Board, professional organizations, legal counsel and the citizens of Ohio. In the end however, it is the state legislature that determines the contents of the NPA. As the Board of Nursing is the implementation aspect of the NPA governing nurses and nursing, some knowledge of how it is composed and formed may be helpful in understanding the rulings it makes, and how to appeal or question its decisions.

The Ohio Board of Nursing is composed of thirteen members picked by the Governor of Ohio specifically for this duty (ORC, 4723.02). Eight of the members are to be RNs. Of these at least one member must be a practitioner of a specialty such as; a certified nurse midwife, a clinical nurse specialist, a certified nurse practitioner, or a certified nurse anesthetist. Of the five remaining positions on the Board four of those seats are reserved for LPNs, with the last remaining seat being occupied by what is referred to as a 'consumer interest' representative (ORC, 4723.02).

Each of the LPN and RN members are required to have met certain minimum standards. Each must be a graduate of an approved nursing education program and hold a current license in the state of Ohio for the profession of nursing. Each of these board members must also have actively been in practice in their profession for the five years immediately prior to being selected for a position on the Board of Nursing.

That odd man out, the single citizen consumer interest representative, is forced to meet requirements that in many ways are the opposite of the nurses seated on the Board. The consumer representative is required to not be a member of any healthcare profession. Neither may they or anyone in their family be employed in healthcare. As a further requirement there can be no financial association related to financing or delivering health related items or services.

This group composing the Board of Nursing is charged with administering and enforcing the Nursing Practice Act and is equipped with an array of clearly defined powers, duties and responsibilities.

Now that we have an image of the players, we will take a look at the script they interpret, enforce and protect.

No one is allowed to practice a nursing profession in Ohio without a license from the Ohio Board of Nursing. This includes RN, LPN, CRNA, CNS, CNM, CNP, APRN (ORC, 4723.03).

A NPA defines the conditions under which a person can be called by the professional title "nurse" (ORC, 4723.01). To be known as a nurse in Ohio, an application must be presented to the state Board of Nursing (ORC 4723.09). This application will serve as a request to take the licensing examination. (We will discuss transferring out-of-state licenses into Ohio later). For a fee, determined by the Board, the application for examination follows a process described in the NPA that will determine if the educational program you have attended meets the minimum level acceptable for your requested credential. A criminal record background check is also conducted and a testing date and location assigned. Once the testing is successfully completed a discipline specific license is issued by the Board, along with instructions on how to maintain up-to-date licensure by means of Board approved continuing education courses.

Nurses who possess active licenses outside of Ohio who are requesting an Ohio nursing license, known as by licensure by endorsement, may apply to the board to grant them Ohio licensure. Ohio's board of nursing is willing to grant endorsement provided a clean criminal and disciplinary action background check comes back and the applicant provides proof of graduation from an education program approved either by Ohio (or a fellow member of the national council of state boards of nursing), along with documentation of completion of at least two contact hours of continuing education directly related to the laws and rules that govern the practice of nursing in Ohio (ORC 4723.09) (OAC, 4723-7-05). Foreign born applicants seeking a nursing license in the state of Ohio that possess licensure out of the country are required to provide proof that they have passed the Test of English as a Foreign Language (TOEFL) (OAC, 4723-7-04).

Don't despair. A one-hundred-eighty day temporary permit to practice nursing is available to those who are having trouble getting their documentation together as long as they have a current license from a recognized state or national nursing board. However, do not get complacent either. You can only be issued that temporary permit once.

Certifications are recognized in nursing by the NPA (ORC, 4723.24). Proof of successful completion of an approved program specific for that certification and specialty, along with proof of current acceptance by the nationally approved certifying body for that specialty (along with the proper application and fee) allow those individuals consideration by the Board for specialty licensure. No set testing regimen is required, however a criminal record check, continuing education, and maintenance of national certification are mandatory.

Prescriptive authority for APNs may be granted by the Board in compliance with specific criteria in the NPA (ORC, 4723.071) (OAC 4723-8).

To gain the ability to prescribe certain types of medications and/or therapies, a certified nurse practitioner, clinical nurse specialist or certified nurse-midwife must provide proof of 'Collaboration' with a physician with whom they have a standard care arrangement. Proof must be provided that guidance and communication is continuously available in person, by phone, radio or other form of communication. Completion of an approved advanced pharmacology program and a closely supervised 'externship' as detailed in the NPA must also accompany the application for prescriptive authority.

The Legislature in each state may set in place rules and standards separate from any professional organization. For health professionals the acts they may or may not do (as well as a minimum standard for measuring professional competency) are defined by the state in which they choose to practice or be employed.

The intent of a Nurse Practice Act is to protect the public from unsafe practitioners, with the ultimate goal of competent, quality nursing care provided by qualified practitioners. The Nurse Practice Act also protects you, the nurse, by defining what is and what is not a responsibility or duty required from you!

In Ohio, Registered Nurses (RNs) are expected to provide nursing care in a manner defined by the Board of Nursing, as stipulated within the NPA. What is expected, at a minimum, is composed of the following (ORC, 4723.01 (B)-(D)), (OAC, 4723-4-03):

Maintenance of current knowledge in the areas of duties, responsibilities and accountabilities required for safe nursing practice.

The ability to demonstrate both competence and accountability in all of the areas of practice in which that nurse is engaged. This includes, but is not limited to the following;

Consistent performance in all aspects of nursing care.

The ability to assess health status for the purpose of providing nursing care.

Health counseling and teaching abilities.

Skills for safe administration of medications, treatments, executing regimens appropriate for a nurse's professional practice.

The ability to recognize and intervene appropriately when a complication arises, as well as the ability to refer or consult when needed.

Duties that registered nurses are expected to complete within a "timely manner" include the following:

Implementation of any order for a client unless the registered nurse believes or should have reason to believe the order is;

Inaccurate

Not properly authorized

Not current or valid

Harmful or potentially harmful to that client

Contraindicated by other documented information

Clarify any order for a client when the registered nurse believes or should have reason to believe the order is;

Inaccurate

Not properly authorized

Not current or valid

Harmful or potentially harmful to that client

Contraindicated by other documented information

When it is necessary to clarify an order the registered nurse is expected to (in a timely manner) consult with an appropriate licensed practitioner. If a decision is made not to follow the direction or administer the medication or treatment as ordered it is up to the registered nurse to notify the prescribing practitioner (again in a timely manner) and document the notification along with the reason for not following the order. The most important thing however is the mandate to take actions as needed to assure the safety of the client.

The NPA requires a registered nurse to report or consult whenever necessary with other members of the health care team, as well as make referrals if that seems appropriate. While doing so, care must be taken to maintain client confidentiality and limit the communication of nonessential information to other health professionals as much as possible. What would be optimal is to involve the client by allowing consent decisions regarding what information may be communicated to others. This includes the use of written consent permissions in all circumstances appropriate for their use.

It is expected that registered nurses practicing in Ohio maintain acceptable standards of safe nursing care in the areas of observation, advice, instruction, teaching, or evaluation. They are also expected to communicate information in an acceptable manner within the standards of safe nursing care. This includes identifying their title to the person with whom they are communicating.

When providing direction to a licensed practical nurse, it is up to the registered nurse to first assess:

The condition of the client, including their stability

The type of nursing care required by the client

The complexity and frequency of any nursing care needed

The training, skill and ability of that licensed practical nurse in relation to their ability to perform specific needed functions or procedures

The availability and accessibility of resources needed in order to safely perform the specified function or procedure

The eternal question "Vocational vs. Practical" is answered by the Ohio NPA. In Ohio, the title is LPN Licensed Practical Nurse.

The practice of nursing as a licensed practical nurse" means providing to individuals and groups nursing care requiring the application of basic knowledge of the biological, physical, behavioral, social, and nursing sciences at the direction of a registered nurse or any of the following who is authorized to practice in this state: a physician, physician assistant, dentist, podiatrist, optometrist, or chiropractor (ORC 4723.01(6)(f).

The Standards of Practice for a Licensed Practical Nurse is the LPN is expected to function within the limits of practice set out by the Ohio Revised Code as well as by any rules by the Board of Nursing, applicable laws, rules and professional standards (ORC, 4723.01(E)-(F)), (OAC, 4723-4-04):

It is an expectation that current knowledge of duties, responsibilities and accountabilities necessary for safe nursing practice be maintained, and that a licensed practical nurse is able to demonstrate competence and accountability in the care that they deliver. Licensed Practical Nurses are also expected to possess the skills necessary to recognize, refer, seek consultation or implement interventions that may be needed to handle complications which may arise.

In the state of Ohio, it is expected that a licensed practical nurse will, in a timely manner, complete the following:

Implement any order or direction for a client unless the licensed practical nurse believes or should have reason to believe the order is;

Inaccurate

Not properly authorized

Not current or valid

Contraindicated by other documented information

Obtain clarification for any order or direction for a client when the licensed practical nurse believes or should have reason to believe the order or direction is;

Inaccurate

Not properly authorized

Not current or valid

Contraindicated by other documented information

Clarification for an order or direction requires a timely consultation with an appropriate licensed practitioner and notification of the prescribing practitioner should the licensed practical nurse make a decision not to follow the direction or administer the medication or treatment as prescribed. This must be followed with documentation that the practitioner was notified of the decision as well as the reason for that decision. Above all, the licensed practical nurse is expected to take action when needed to assure the safety of the client.

A licensed practical nurse is expected to report to and consult with other nurses or members of the health care team in a timely manner. They are also expected to make referrals for the client as appropriate. When discussing client information with other health providers the licensed practical nurse must maintain client confidentiality to the greatest extent possible. As much as possible it is desired that the client have the right to give or withhold consent regarding the release of information. This includes the use of written consents when appropriate or in all circumstances identified by law.

In those instances, in which a licensed practical nurse is directed to observe, advise, instruct, or evaluate the performance of a nursing task they are expected to use acceptable standards of safe nursing care as a basis. Any information they communicate should be within the acceptable standards of safe nursing care.

Licensed Practical Nurses (LPNs) in Ohio may be eligible for Intravenous Therapy privileges after licensure in the state (ORC, 4723.18), (OAC, 4723-18), If this is desired they must demonstrate successful completion of a Board approved course of study in the safe performance of Intravenous Therapy. The laws for IV therapy by LPNs are very specific.

When a licensed practical nurse authorized by the board to perform intravenous therapy performs an intravenous therapy procedure at the direction of a registered nurse, the registered nurse or another registered nurse shall be readily available at the site where the intravenous therapy is performed, and before the licensed practical nurse initiates the intravenous therapy, the registered nurse shall personally perform an on-site assessment of the adult patient who is to receive the intravenous therapy. (OAC, 4723-18 (2)(C)(1))

There are special requirements for LPNs to perform intravenous therapy procedures. The following are those requirements (OAC, 4723-18 (2)(D)- 4723.181(5))

(D) No licensed practical nurse shall perform any of the following intravenous therapy procedures:

(1) Initiating or maintaining any of the following:

(a) Blood or blood components;

(b) Solutions for total parenteral nutrition;

(c) Any cancer therapeutic medication including, but not limited to, cancer chemotherapy or an anti-neoplastic agent;

(d) Solutions administered through any central venous line or arterial line or any other line that does not terminate in a peripheral vein, except that a licensed practical nurse authorized by the board to perform intravenous therapy may maintain the solutions specified in division (D)(6)(a) of this section that are being administered through a central venous line or peripherally inserted central catheter;

(e) Any investigational or experimental medication.

(2) Initiating intravenous therapy in any vein, except that a licensed practical nurse authorized by the board to perform intravenous therapy may initiate intravenous therapy in accordance with this section in a vein of the hand, forearm, or antecubital fossa;

(3) Discontinuing a central venous, arterial, or any other line that does not terminate in a peripheral vein;

(5) Mixing, preparing, or reconstituting any medication for intravenous therapy, except that a licensed practical nurse authorized by the board to perform intravenous therapy may prepare or reconstitute an antibiotic additive;

(6) Administering medication via the intravenous route, including all of the following activities:

(a) Adding medication to an intravenous solution or to an existing infusion, except that a licensed practical nurse authorized by the board to perform intravenous therapy may do any of the following:

(ii) Hang subsequent containers of the intravenous solutions specified in division (D)(6)(a)(i) of this section that contain vitamins or electrolytes, if a registered nurse initiated the infusion of that same intravenous solution.

(b) Injecting medication via a direct intravenous route, except that a licensed practical nurse authorized by the board to perform intravenous therapy may inject heparin or normal saline to flush an intermittent infusion device or heparin lock including, but not limited to, bolus or push.

Changing tubing on any line including, but not limited to, an arterial line or a central venous line, except that a licensed practical nurse authorized by the board to perform intravenous therapy may change tubing on an intravenous line that terminates in a peripheral vein;

(8) Programming or setting any function of a patient controlled infusion pump.

(E) Notwithstanding divisions (A) and (D) of this section, at the direction of a physician or a registered nurse, a licensed practical nurse authorized by the board to perform intravenous therapy may perform the following activities for the purpose of performing dialysis:

(1) The routine administration and regulation of saline solution for the purpose of maintaining an established fluid plan;

(2) The administration of a heparin dose intravenously;

(3) The administration of a heparin dose peripherally via a fistula needle;

(4) The loading and activation of a constant infusion pump or the;

(5) The intermittent injection of a dose of medication physician for dialysis that is administered via the hemodialysis blood circuit and through the patient's venous access.

(F) No person shall employ or direct a licensed practical nurse to perform an intravenous therapy procedure without first verifying that the licensed practical nurse is authorized by the board to perform intravenous therapy.

QRC Sec. 4723.181. (A) A licensed practical nurse may perform on any person any of the intravenous therapy procedures specified in division (B) of this section without receiving authorization to perform intravenous therapy from the board of nursing under section 4723.17-4723.18 of the Revised Code, if both of the following apply:

(1) The licensed practical nurse acts at the direction of a registered nurse or a licensed physician, dentist, optometrist, or podiatrist and the registered nurse, physician, dentist,
optometrist, or podiatrist is on the premises where the procedure is to be performed or accessible by some form of telecommunication.

(2) The licensed practical nurse can demonstrate the knowledge, skills, and ability to perform the procedure safely.

(B) The intravenous therapy procedures that a licensed practical nurse may perform pursuant to division (A) of this section are limited to the following:

(1) Verification of the type of peripheral intravenous solution being administered;

(2) Examination of a peripheral infusion site and the extremity for possible infiltration;

(3) Regulation of a peripheral intravenous infusion according to the prescribed flow rate;

(4) Discontinuation of a peripheral intravenous device at the appropriate time;

The nursing process and dedicated nurses have been shown to be valuable in every area of health care. The state of Ohio in its NPA recognizes that nurses can be found everywhere, doing many different tasks at all levels of care. For that reason, it has specifically addressed the standards it expects from the following Advance Practice Nurses (APN) (ORC, 4723.01(G)-(J)), (OAC, 4723-4-05):

Certified Nurse Midwife

Certified Nurse Practitioner

Certified Registered Nurse Anesthetist

Clinical Nurse Specialist

In addition to meeting the qualifications laid out in section 4723.01 of the Ohio Revised Code along with the rules of the Board of Nursing, these APNs are held to a higher standard of practice should that individual hold a certificate to prescribe medications.

In essence, these sections of the NPA set a standard by which these advanced care providers may be evaluated, and describes the process of evaluation along with who will provide that service (collaborating physician, specialist, or nurse holding a similar current certificate of authority). These advanced nurse practitioners must provide proof of education from a recognized body of knowledge relative to the nursing care they will provide as well as demonstrating appropriate knowledge/skills/abilities and the ability to maintain satisfactory documentation as set forth by the Board of Nursing for their specialty.

Advance care providers are required to have a standard care arrangement (OAC, 4723-8-01). This arrangement is a written, formal guide for planning and evaluating a patient's health care that is developed by a collaborating physician or podiatrist and a certified nurse-midwife, certified nurse practitioner, or clinical nurse specialist,

(G) "Collaboration" or "collaborating" means (OAC, 4723-8-01(G)):

(1) In the case of a certified nurse practitioner or a clinical nurse specialist, except as provided in paragraph (G)(2) of this rule, that a podiatrist or physician has entered into a standard care arrangement with the nurse and is continuously available to communicate with the clinical nurse specialist or certified nurse practitioner either in person, or by radio, telephone, or other form of telecommunication;

(2) In the case of a clinical nurse specialist whose nursing specialty is mental health or psychiatric mental health, that a physician is continuously available to communicate with the nurse either in person, or by radio, telephone, or other form of telecommunication; or

(3) In the case of a certified nurse-midwife, that a physician has entered into a standard care arrangement with the nurse and is continuously available to communicate with the nurse either in person, or by radio, telephone, or other form of telecommunication.

Recent Changes

HB 341 imposes new legal requirements for CTP holders. CTP holders who hold appropriate DEA certification and prescribe opioid analgesics or benzodiazepines…before initially prescribing or personally furnishing an opioid analgesic or a benzodiazepine, must request patient information from OARRS that covers at least the previous 12 months, and make periodic requests for patient information from OARRS if the course of treatment continues for more than 90 days. Exceptions to the requirement to check OARRS under these circumstances include drugs prescribed to hospice or cancer patients, drugs to be administered in hospitals or long-term facilities, drugs to treat acute pain from surgery or a delivery, and drug amounts for use in seven days or less. The law further requires the Nursing Board to verify that licensees prescribing in this manner are registered and using OARRS appropriately. Violations of these legal requirements may subject licensees to discipline (OBN Momentum, winter 2015, pg. 6).

Recent amendments to the Ohio Nurse Practice Act permits APRNs with prescriptive authority to delegate the administration of certain drugs under specified conditions. This new delegation authority became effective October 15, 2015 through the enactment of Senate Bill 110 (131st General Assembly). Section 4723.48, Ohio Revised Code (ORC), permits the holder of a certificate to prescribe (CTP), to delegate to a person not otherwise authorized to administer drugs, the authority to administer drugs to a specified patient. Prior to delegating this authority, the CTP holder is required to assess the patient, determine that the drug is appropriate for the patient, and determine that the person to whom the authority will be delegated has met the conditions specified in division (D) of Section 4723.489, ORC. Section 4723.489, ORC, specifies the conditions under which the delegation may occur. For example, a CTP holder is limited to delegating only the administration of drugs that the CTP holder may prescribe him/herself, and the CTP holder is prohibited from delegating the administration of intravenous drugs and controlled substances. There are also restrictions on the locations where the authority to administer drugs may be delegated by a CTP holder. Section 4723.489(C), ORC, prohibits the delegation from occurring in hospital inpatient care units, hospital emergency departments, freestanding emergency departments, or ambulatory surgery facilities. The CTP holder must be physically present at all locations where a drug is administered through CTP holder delegation. Prior to delegating, the CTP holder must determine that the individual who will administer the drugs has successfully completed drug administration education based upon a recognized body of knowledge, and that the individual has demonstrated to their employer the knowledge, skills, and ability to safely administer the drug(s). All of this must be documented and made available to the delegating CTP holder to determine whether the delegation is appropriate for patient safety and well-being. (OBN Momentum, fall 2015, pg. 14).

(A) Prior to engaging in practice, a standard care arrangement shall be entered into with each physician or podiatrist with whom the certified nurse-midwife, certified nurse practitioner, or clinical nurse specialist collaborates.

(1) The standard care arrangement shall be revised to reflect the addition or deletion of a physician or podiatrist with whom the nurse collaborates within that employment setting. Under these circumstances, a new standard care arrangement is not necessary.

(2) A new standard care arrangement shall be executed when the nurse is employed at a different setting and engages in practice with a different collaborating physician or podiatrist.

(B) A certified nurse-midwife, certified nurse practitioner, or clinical nurse specialist engaged in the practice of the nurse's specialty, shall enter into a written standard care arrangement with one or more collaborating physicians or podiatrists whose practice is the same or similar to the nurse's practice. In accordance with division (D) of section 4723.431 of the Revised Code, a clinical nurse specialist without a certificate to prescribe whose nursing specialty is mental health or psychiatric mental health is not required to enter into a standard care arrangement.

(C) The standard care arrangement shall include at least:

(1) The signatures of each nurse, and each collaborating physician, or the physician's designated representative, or each podiatrist with whom the certified nurse-midwife, certified nurse practitioner, or clinical nurse specialist primarily collaborates indicating review of and agreement to abide by the terms of the standard care arrangement. For purposes of this rule, a physician's designated representative means a physician who serves as the department or unit director or chair, within the same institution, organization or facility department or unit, and within the same practice specialty, that the nurse practices, and with respect to whom the physician has executed a legal authorization to enter collaborating agreements on the physician's behalf;

(2) The date when the arrangement is initially executed;

(3) The date of the most recent review of the arrangement;

(4) The complete name, specialty and practice area, business address, and business phone number or number at which the individual can be reached at any time for:

(a) Each collaborating physician or podiatrist with whom the certified nurse-midwife, certified nurse practitioner, or clinical nurse specialist primarily collaborates and who is a party to the standard care arrangement; and

(b) Each certified nurse-midwife, certified nurse practitioner, or clinical nurse specialist who is a party to the standard care arrangement;

(5) A statement of services offered by the certified nurse-midwife, certified nurse practitioner, or clinical nurse specialist consistent with section 4723.43 of the Revised Code and this chapter. For holders of a certificate to prescribe, there shall also be a description of the scope of prescriptive practice.

(6) A plan for incorporation of new technology or procedures consistent with the applicable scope of practice as set forth in section 4723.43 of the Revised Code and this chapter;

(7) Quality assurance provisions, including at least:

(a) Every two years, review and reapproval of the standard care arrangement. The standard care arrangement shall be reviewed at least every two years. Each nurse who is a party to the arrangement and at least one collaborating physician or podiatrist shall sign and date the biennial review of the standard care arrangement;

(b) Criteria for referral of a patient by the certified nurse-midwife, certified nurse practitioner, or clinical nurse specialist to a collaborating physician or podiatrist, including, for the certified nurse-midwife, a plan for referral of breech or face presentation or any other abnormal condition identified as such in the standard care arrangement;

(c) A process for the certified nurse-midwife, certified nurse practitioner, or clinical nurse specialist to obtain consultation from a physician or podiatrist;

(d) A procedure for regular review of referrals made by the certified nurse-midwife, certified nurse practitioner, or clinical nurse specialist to other health care professionals, and the care outcomes for a representative sample of all patients seen by the nurse; and

(e) A process for chart review in accordance with rule 4723-8-05 of the Administrative Code if the nurse's practice includes any direct patient care, education, or management;

(8) A policy for care of infants up to age one and recommendations for collaborating physician visits for children from birth to age three, if the nurse is providing services to infants;

(9) A plan for coverage of patients in instances of emergency or planned absences of either the certified nurse-midwife, certified nurse practitioner, or clinical nurse specialist, or the collaborating physician or podiatrist;

(10) A process for resolution of disagreements regarding matters of patient management; and

(11) An arrangement regarding reimbursement under the medical assistance program as set forth in Chapter 5162. of the Revised Code and in accordance with any rules adopted under division (B) of section 5164.02 of the Revised Code.

(12) For nurses with a current valid certificate to prescribe, the following quality assurance provisions shall include at least:

(a) Provisions to ensure timely direct, personal evaluation of the patient with a collaborating physician or the physician's designee when indicated;

(b) Additional prescribing parameters for those drugs or therapeutic devices established in the formulary, http://www.nursing.ohio.gov/Practice-CTP.htm (effective 2015), including:

(i) Provisions for use of drugs with non-food and drug administration (FDA) approved indications;

(ii) Provisions for use of drugs approved by the FDA and reviewed by the committee on prescriptive governance subsequent to the date of the standard care arrangement;

(iii) Provisions for use of drugs previously reviewed by the committee on prescriptive governance but approved by the FDA for new indications subsequent to the date of the standard care arrangement; and

(iv) Provisions for the use of schedule II controlled substances.

(v) If the nurse is prescribing to minors, as defined in division (A) of section 3719.061 of the Revised Code, provisions for complying with section 3719.061 of the Revised Code when prescribing an opioid analgesic to a minor; and

(vi) Provisions for obtaining and reviewing OARRS reports, and engaging in physician consultation and patient care consistent with section 4723.487 of the Revised Code and rule 4723-9-12 of the Administrative Code.

(c) A procedure for the nurse and the collaborating physician, or a designated member of a quality assurance committee, composed of at least one physician, of the institution, organization, or agency where the nurse has practiced during the period covered by the review, to conduct a periodic review, at least semiannually, of:

(i) A representative sample of prescriptions written by the nurse;

(ii) A representative sample of schedule II prescriptions written by the nurse; and

(d) Provisions to ensure that the nurse is meeting all the requirements of rule 4723-9-12 of the Administrative Code related to review of a patient's OARRS report, consultation with the collaborating physician prior to prescribing based on the OARRS report and signs of drug abuse or diversion as set forth in rule 4723-9-12 of the Administrative Code, and documentation of receipt and assessment of OARRS report information in the patient's record.

(D) The most current copy of the standard care arrangement, and any legal authorization signed by a physician according to paragraph (C)(1) of this rule, shall be retained and be available upon request at each site where practice of the certified nurse-midwife, certified nurse practitioner, or clinical nurse specialist occurs. Upon request of the board, the certified nurse-midwife, certified nurse practitioner, or clinical nurse specialist shall immediately provide a copy of the standard care arrangement to the board.

(E) Copies of previously effective standard care arrangements shall be retained by the nurse for three years and provided to the board upon request.

(F) When a hospital negotiates a standard care arrangement in accordance with division (E) of section 4723.431 of the Revised Code and this chapter, the standard care arrangement shall be developed in accordance with paragraph (C) of this rule. Review and approval of the standard care arrangement shall be in accordance with the policies and procedures of the hospital governing body and the bylaws, policies, and procedures of the hospital medical staff.

(G) A certified nurse-midwife, certified nurse practitioner, or clinical nurse specialist shall notify the board of the identity of a collaborating physician or podiatrist not later than thirty days after engaging in practice.

(H) A certified nurse-midwife, certified nurse practitioner, or clinical nurse specialist shall notify the board of any change in the name and business address of a collaborating physician or podiatrist not later than thirty days after the change takes effect.

(I) A clinical nurse specialist who does not hold a certificate to prescribe and whose nursing specialty is mental health or psychiatric mental health is exempt from the requirement of executing a standard care arrangement in accordance with division (D)(1) of section 4723.431 of the Revised Code. The clinical nurse specialist who does not hold a certificate to prescribe and whose nursing specialty is mental health or psychiatric mental health shall identify one or more physicians with whom the nurse collaborates in accordance with division (D)(1) of section 4723.431 of the Revised Code.

(J) A clinical nurse specialist who holds a certificate to prescribe and whose nursing specialty is mental health or psychiatric mental health shall enter into a standard care arrangement in accordance with division (D)(2) of section 4723.431 of the Revised Code.

4723-8-05 [Effective 2/1/2016] Quality assurance standards.

(A) A holder of a current valid certificate of authority shall comply with all continuing education requirements for registered nurse license renewal set forth in division (C) of section 4723.24 of the Revised Code and national certification requirements set forth in sections 4723.41 and 4723.42 of the Revised Code and this chapter.

(B) The certified nurse-midwife, certified nurse practitioner, or clinical nurse specialist and the collaborating physician or podiatrist shall jointly review each effective standard care arrangement at least once every two years Such review shall be documented with the date and signature of each nurse who is party to the arrangement and at least one collaborating physician or podiatrist.

(C) Each certified nurse-midwife, certified nurse practitioner, and clinical nurse specialist who is a party to a standard care arrangement shall comply with all quality assurance provisions of the standard care arrangement in accordance with this chapter. Failure to provide, enter into, or to practice in accordance with a standard care arrangement may result in disciplinary action in accordance with section 4723.28 of the Revised Code.

(D) Each practicing advanced practice registered nurse shall participate in a quality assurance process and shall immediately provide documentation satisfactory to the board of such participation upon request of the board. The quality assurance process shall include at a minimum:

(1) Periodic random chart review at least annually by a collaborating or supervising physician, podiatrist, dentist, or a designated member of a quality assurance committee, composed of at least one physician, of the institution, organization, or agency where the nurse has practiced during the period covered by the review. If the nurse holds prescriptive authority, the process shall include a procedure for periodic review, at least semi-annually, of prescriptions written and prescribing patterns for the holder of a certificate to prescribe;

(2) Subsequent to each chart review, a conference shall be held between a collaborating or supervising physician, podiatrist, dentist, or a designated member of a quality assurance committee of the institution, organization, or agency and the advanced practice registered nurse; and

(3) A process for patient evaluation of care.

(E) Documentation of participation in an ongoing, systematic quality assurance process at an institution, organization, or agency shall satisfy the requirements of paragraph (D) of this rule, provided there is a plan to utilize the results of the quality assurance process to maintain or improve care delivery.

(F) Every two years, each certified nurse-midwife, certified nurse practitioner, and clinical nurse specialist shall verify the licensure status of each collaborating physician or podiatrist with whom the nurse has an effective standard care arrangement. Verification of licensure status may be obtained online from the Ohio e-license center. The nurse shall document that such verification was obtained.

(G) The board may audit, review or investigate, at any time, whether an advanced practice registered nurse has complied with the quality assurance standards set forth in this rule.

4723-8-06 [Effective 2/1/2016] National certifying organizations.

(A) To be approved by the board, a national certifying organization shall meet all of the requirements set forth in division (A) of section 4723.46 of the Revised Code.

(B) Annually at a time specified by the board, the board shall provide to each national nursing certifying organization approved by the board for the prior year a form, located at http://www.nursing.ohio.gov/forms.htm (revised 2015), for the organization to submit to the board attesting that the organization has met and continues to meet all the requirements contained in section 4723.46 of the Revised Code. The board shall verify compliance of each national nursing certifying organization with the criteria contained in section 4723.46 of the Revised Code. No later than January thirtieth of each year, the board shall publish a list of approved national certifying organizations that meet these requirements. The board may approve additional national nursing certifying organizations or discontinue approval of a national nursing certifying organization based on criteria in section 4723.46 of the Revised Code. At the discretion of the board, it may discontinue approval of a national certifying organization for failure of the organization to return to the board the form indicating compliance with the requirements of section 4723.46 of the Revised Code.

4723-8-07 [Effective 2/1/2016] Initial certificate of authority.

(A) To obtain a certificate of authority to practice as a certified nurse-midwife, certified nurse practitioner, certified registered nurse anesthetist, or clinical nurse specialist, an applicant who meets the qualifications set forth in section 4723.41 of the Revised Code and this chapter shall:

(1) Submit a completed application on the form specified by the board, located at http://www.nursing.ohio.gov/forms.htm (revised 2015), that includes the documentation and meets the requirements set forth in section 4723.41 of the Revised Code; and

(2) Submit an application fee of one hundred dollars.

(B) If an applicant for a certificate of authority fails to meet the requirements for certification within one year from the date the application is received, or the application submitted to the board remains incomplete for one year, the application shall be considered void and the fee submitted with the application shall be forfeited. The application shall state the circumstances under which this forfeiture may occur.

(C) A certificate of authority for an advanced practice registered nurse shall be automatically suspended or revoked, in accordance with section 4723.47 of the Revised Code, when a license to practice as a registered nurse is suspended or revoked. If suspended, the certificate of authority shall remain suspended until the license to practice as a registered nurse is reinstated. A certificate of authority shall automatically lapse or become inactive, in accordance with section 4723.47 of the Revised Code, when a license to practice as a registered nurse is lapsed or made inactive. The certificate of authority shall remain lapsed or inactive until the license to practice as a registered nurse is renewed or reactivated.

(A) To renew a certificate of authority to practice as a certified nurse-midwife, certified nurse practitioner, clinical nurse specialist, or certified registered nurse anesthetist, a holder of a current valid certificate of authority who meets the qualifications set forth in section 4723.41 of the Revised Code and this chapter shall:

(1) Submit a completed renewal application on an application specified by the board, located at http://www.nursing.ohio.gov/forms.htm (revised 2015), that includes:

(a) Except as provided in paragraph (A)(2) of this rule, documentation satisfactory to the board that the holder has maintained certification in the nursing specialty with a national certifying organization as required by division (B) of section 4723.42 of the Revised Code;

(b) A list of the names and business addresses of the holder's current collaborating physicians and podiatrists, if the nurse is a clinical nurse specialist, certified nurse-midwife, or certified nurse practitioner; and

(c) The renewal fee set forth in division (A)(10) of section 4723.08 of the Revised Code. If a completed renewal application is not renewed on-line before July first of odd numbered years, in order to renew the applicant shall pay a late processing fee of fifty dollars in accordance with division (A)(13) of section 4723.08 of the Revised Code. The late processing fee is in addition to the renewal fee specified in division (A)(10) of section 4723.08 of the Revised Code, and is in addition to any late processing fee imposed with respect to renewal of the applicant's registered nurse license; and

(2) A clinical nurse specialist, originally issued a certificate of authority on or before December 31, 2000 in accordance with division (C) of section 4723.41 of the Revised Code, as that division existed prior to March 20, 2013, is not required to provide documentation of having maintained certification in the holder's specialty, but shall submit documentation satisfactory to the board of completion of continuing education in compliance with paragraph (B) of rule 4723-8-10 of the Administrative Code.

(B) A renewed certificate of authority shall be current until the next scheduled renewal period for registered nurse licensure. However, when a certificate of authority is issued by the board on or after the first of March of an odd numbered year, that certificate of authority shall be current through the thirty-first of August of the next odd numbered year.

(C) The board shall provide access to an on-line application to each holder of a current valid certificate of authority an application for renewal of a certificate of authority, except when the board is aware that an individual is ineligible for renewal for any reason, including those reasons specified in division (A) of section 4723.24 of the Revised Code. Failure of the holder to receive an application for renewal from the board does not excuse the holder from the requirements of Chapter 4723 of the Revised Code and this chapter.

(D) Within thirty days of recertification by the applicable national certifying organization, the holder of a certificate of authority shall request that the national certifying organization provide, directly to the board, satisfactory documentation of recertification to the board. This requirement does not apply to a clinical nurse specialist, originally issued a certificate of authority on or before December 31, 2000 in accordance with division (C) of section 4723.41 of the Revised Code, as that division existed prior to March 20, 2013.

(E) A certificate of authority holder who fails to maintain certification or recertification by the applicable national certifying organization approved by the Board according to section 4723.46 of the Revised Code, may be subject to disciplinary action in accordance with section 4723.28 of the Revised Code. This requirement does not apply to a clinical nurse specialist, originally issued a certificate of authority on or before December 31, 2000 in accordance with division (C) of section 4723.41 of the Revised Code, as that division existed prior to March 20, 2013.

(F) A clinical nurse specialist, originally issued a certificate of authority on or before December 31, 2000 in accordance with division (C) of section 4723.41 of the Revised Code, as that division existed prior to March 20, 2013, who fails to complete the continuing nursing education required by division (B) of section 4723.42 of the Revised Code and rule 4723-8-10 of the Administrative Code, may be subject to disciplinary action in accordance with section 4723.28 of the Revised Code.

(G) A holder of a current valid certificate of authority who does not intend to practice as a certified nurse-midwife, certified nurse practitioner, certified registered nurse anesthetist, or clinical nurse specialist in Ohio may request that the certificate of authority be placed on inactive status at any time, by submitting a written statement to the board requesting that the certificate be placed on inactive status.

(H) While on inactive status a nurse shall not represent or imply to the public that the nurse is authorized to practice as a certified nurse-midwife, certified nurse practitioner, certified registered nurse anesthetist, or clinical nurse specialist or use the titles established by section 4723.03 of the Revised Code and rule 4723-8-03 of the Administrative Code.

(I) An inactive or lapsed certificate of authority for an advanced practice registered nurse may be reactivated or reinstated by :

(1) Submitting to the board a completed certificate of authority reactivation and reinstatement application on the form required by the board, located at: http:///www.nursing.ohio.gov/forms.htm (revised 2015) ; and

(2) Payment of the applicable fees set forth in section 4723.08 of the Revised Code.

(J) A certificate holder who is a service member or veteran, as defined in rule 4723-2-01 of the Administrative Code, or who is the spouse or surviving spouse of a service member or veteran, may be eligible for a waiver of the late application fee and the reinstatement fee according to rule 4723-2-03 of the Administrative Code.

A certified nurse-midwife, certified nurse practitioner, certified registered nurse anesthetist, or clinical nurse specialist who is practicing in another jurisdiction may apply for a certificate of authority to practice in Ohio if the nurse meets the requirements for approval for a certificate of authority set forth in section 4723.41 of the Revised Code and this chapter. An applicant from another jurisdiction shall:

(A) Submit a completed application on the form specified by the board, located athttp://www.nursing.ohio.gov/forms.htm (revised 2015); and

It is all about safety really. A NPA serves as a dividing line between what is recognized as a safe level of client care, and what is not. In OAC, 4723-4-06 of the Nurse Practice delineates minimum standards for client safety. One of which is that the title (or initials representing the title) of each nurse offering care be displayed as a means of identifying that person's relevant licensure. This process of identifying level of credential does not stop at a nametag. Whenever engaged in a telephone (or any other means of distance) conversation related to nursing practice each nurse holding a valid Ohio licensure is required to identify their title to the person they are conversing with (OAC, 4723-4-06).

Reporting and documenting complete, accurate and timely nursing assessments is an essential part of client safety. As is documenting the care provided by the nurse for that client and the following response of the client to that care. The process of reporting includes relaying to the appropriate practitioner any errors or deviations from current valid orders. Record management emphasizes truth in reporting and falsifying records or altering documents is strongly discouraged.

The Ohio NPA encourages nurses to implement measures that promote a safe environment for each client and discourages behaviors that cause or may cause physical, verbal, mental or emotional abuse.

Property belonging to a client should not be misappropriated. Nor should there be any behaviors enacted to seek or obtain personal gain at the client's expense. The presence of behavior that may be reasonably interpreted as an attempt to seek personal gain at the client's expense also warrants a caution.

Personal relationships of an inappropriate kind or even the appearance of such relationships is also specifically warned against in the Act. Special attention is paid to care of clients considered incapable of giving free, full or informed consent. Each nurse licensed in Ohio is warned against even the appearance of the following:

Sexual conduct with a client.

Conduct in the course of practice that may be reasonably interpreted as sexual.

Verbal behavior of the seductive or sexually demeaning type.

Verbal behavior that to the client may be reasonably interpreted as seductive or sexually demeaning.

It is an expectation in Ohio that each nurse delineates, establishes and maintains professional boundaries with each client. As a routine matter of care the nurse should provide privacy during examination or treatment, and treat each client with courtesy, respect and with full recognition of dignity.

One of the most consistently productive instruments available to health care is the Nursing Process. The OAC, 4723-4-07 recognizes the importance of the nursing process and defines it as steps which are "cyclical in nature so that the nurse's actions are directed by the client's changing status throughout the process" (OAC, 4723-4-07).

The nurse collaborates with client, family, significant others, as well as other members of the health care team in applying the steps of the nursing process. Licensed practical nurses provide a valuable role in obtaining data, implementing strategies, and collaborating during the entire course of care. Registered nurses and advanced care nurses introduce critical thinking and clinical judgment into the application of the following steps:

Assessment

Collect data both subjective and objective from all involved persons either in person or by delegation.

Document the collected data.

Report data as appropriate to other health team members.

Analysis

Identify, organize and interpret relevant data.

Establish, accept or modify a nursing diagnosis to be used as a basis for nursing interventions.

Planning

Develop, maintain, or modify the nursing component of the plan for care including establishing desired client outcomes and interventions.

Communicate the nursing component of the plan for care and all modifications of the plan to appropriate members of the health team.

Implementation

Execute any current valid orders or directions by those authorized to practice in Ohio as is within the course of that individuals professional practice.

Many states require proof of ongoing professional learning as a condition for gaining and renewing a license to practice nursing in their jurisdiction. As an example we will look at the continuing professional education expectations as outlined in the Ohio NPA.

License renewal for nurses in Ohio is on a two year cycle. Every two years nurses must complete and possess documentation that they have completed twenty-four contact hours of professional level nursing continuing education, one hour of which must be a category A level training.

For those who come to a renewal date after holding an Ohio licensure for one year or less there is a lessened expectation of twelve hours of professional level nursing continuing education. If an individual has held an Ohio license for more than one year, they are held to the higher renewal standard of twenty-four hours.

Each applicant for renewal must attest that they have completed the required number and levels of continuing education within the two year time window. Documented evidence of completion must be available on request by the board. Should evidence of completion be lacking and the applicant fail to provide proof to the board before the end of the renewal period the license will lapse.

To reactivate or reinstate a lapsed license the nurse applicant will need to complete twenty-four contact hours of continuing education, with one of the hours being a category A, and possess documentation that completion occurred during the twenty-four month period immediately before their reapplication date.

Applicant must complete 24 Contact Hours during the twenty-four month period immediately before the application date.

If the license of a registered nurse or licensed practical nurse has been inactive or lapsed in Ohio less than two years, or the applicant holds a current, valid license in another jurisdiction, the continuing education shall be 24 Contact Hours of continuing education that includes one hour of category "A".

If the license of a registered nurse or licensed practical nurse has been inactive or lapsed in Ohio for two years or more, and the applicant does not hold a current, valid license in another jurisdiction, the continuing education must consist of 24 Contact Hours and must include all of the following:

(a) Two contact hours of category A with learning outcome that address scopes of practice for registered and licensed practical nurses, standards of safe practice, and nursing delegation;

(b) Six contact hours with learning outcome that address application of the nursing process and critical thinking, clinical reasoning, or nursing judgment related to patient care;

(c) Six contact hours in pharmacology with learning outcome that include drug classifications, medication errors, and patient safety;

(d) Two contact hours that include learning outcome related to clinical or organizational ethical principles in health care; and

(e) Eight contact hours that include learning outcome related to an area relevant to the nurse's practice.

Remember the Board? The Board of Nursing is the implementation aspect of the Ohio Nurse Practice Act. You might choose to think of it as the end with the teeth.

You need to know the Nurse Practice Act from the governing
body you are responsible to! Do not wait until it is too late.

"Ignorance of the law is no excuse!"

The NPA spells out the process by which the Board investigates evidence having the appearance that a licensee or certificate holder has failed to practice in accordance with acceptable standards of safe practice. Once evidence has been gathered a review by the Board determines wrongdoing, lack of wrongdoing, or the presence of a deficiency in practice without actual harm or risk of imminent serious harm (for which a less stringent correction alternative may be offered by the NPA) (ORC, 4723.28).

Powers held by the Board include the ability to deny a license or certificate to practice within the state. License or certificates can also be suspended or revoked; the holder reprimanded, fined, or forwarded for criminal prosecution in instances of extreme neglect or suspected abuse (ORC, 4723.02).

Not all reasons for discipline are major violations. The Board oversees all aspects of nursing practice within the area of its jurisdiction, and may choose to investigate and discipline such things as reports of a nurse license holder not using universal and standard infection control precautions (OAC, 4723-07), offering to 'waive' client fees/co-payments or otherwise alter billing records as applies to nursing services (ORC, 4723.28), or even reports of a nurse supplying more than a 72-hour quantity of sample medications or therapeutic devices (ORC, 4723.481).

It is an assigned duty for the Board to investigate evidence that appears to show a violation has occurred. Disciplinary proceedings that take place after an investigation may either appear before a hearing examiner or they may be resolved by a consent agreement. When findings indicate that an individuals practice is substandard yet not posing a serious risk the Board can recommend participation in the state guided practice intervention and improvement program (PIIP) rather than formal disciplinary action (OAC, 4723-6).

It is possible to request a hearing from the Board and agreeing to monitored progress while participating in the PIIP may be an option for those willing to work with the Board to correct minor practice deficiencies, or the appearance of deficiency. However, it is considered to be the wisest practice to be aware of the standards set concerning nursing practice by your state, and make sure your own practice lays far over onto the smiling side of the line!

Nurse Practice Acts are the definition set by a state for what a nurse is, and what requirements they must meet in order to practice within that state. The Practice Act is put in place for the protection of the public and when we seek initial licensure or renewal of license from a state we are agreeing to practice our profession in such a manner as to meet or exceed the level of care that they have set for us.

In Ohio we have seen an example of a well crafted Nurse Practice Act. An Act that recognizes the many functions, and levels at which a professional nurse might practice. Recognition of professional nursing practice, in particular, as a specific and special means for the provision of nursing care indicates understanding of what nurses are, and what nurses do.

Do you know what you are supposed to be? What you are allowed to do?

You may. Yet I challenge you to take that extra step to be sure. Read YOUR Nurse Practice Act! You may be surprised by what you find there.

Just maybe, at some time to come, you might be very glad you took the time to find out what your state expects of you!